"Don't Sleep with Big Knives"; Interesting (and Promising) Developments in the Mother-Infant Sleep Debate

In November 9, 2011, amid much fanfare and media attention, the city of Milwaukee unveiled their latest campaign to promote safe infant sleep.

city of milwaukee

The City of Milwaukee launches their most-recent
infant sleep campaign.

The City of Milwaukee launches their most-recent infant sleep campaign.

The images are disturbing to say the least—they were designed that way. “Co-sleeping deaths are the most preventable form of infant death in this community,” Barrett said.  “Is it shocking? Is it provocative?” asked Baker, the health commissioner. “Yes. But what is even more shocking and provocative is that 30 developed and underdeveloped countries have better (infant death) rates than Milwaukee.”  A campaign such as this has a noble goal: to prevent infants from dying. But does this type of campaign keep infants safe?  The tragic answer is “no.” In less than two months after this campaign was launched, two more infants had died in Milwaukee in what the press described as “cosleeping deaths.”http://www.jsonline.com/news/milwaukee/ad-campaign-unveiled-as-another-cosleeping-death-is-announced-s030073-133552808.html

On January 3, 2012, WITI-TV, the affiliate Fox News in Milwaukee reported this:

One-Month-Old Infant Dies in Co-Sleeping Incident

Medical Examiner’s Report Says Baby Was Sleeping On Floor with Three Other Children

     The second death was of a 10-day-old infant who had died while sleeping with three other children on an adult bed. http://www.fox6now.com/news/witi-20111118-sleep-message,0,4692090.story  Neither of these infant sleep locations was safe and should not be classified as “bedsharing deaths.” The sad take-away we can learn from these cases is that “simple messages,” may be headline-grabbing. But in the end, they do not communicate what parents need to know to keep their infants safe while sleeping.

 In the same month as the Milwaukee campaign was launched, the American Academy of Pediatrics issued their new policy statement and follow-up technical report (American Academy of Pediatrics & Task Force on Sudden Infant Death Syndrome, 2011a, 2011b) on infant sleep-related deaths. In their press release, they stated that they were “expanding [the AAP guidelines] on safe sleep for babies, with additional information for parents on creating a safe environment for their babies to sleep.” http://aappolicy.aappublications.org/cgi/content/full/pediatrics;105/3/650

MJS infant

Poster from the Milwaukee campaign
designed to warn against
the dangers of bedsharing.

Poster from the Milwaukee campaign designed to warn against the dangers of bedsharing.

When I first read through this statement, it didn’t seem to differ all that much from previous statements, particularly on the issue many of us are interested in—namely, their recommendations regarding bedsharing. That recommendation did not really change. But in reading the full statement, there were some interesting, and dare I say hopeful, developments.

   The AAP Policy Statement (2011a) lists their Levels A, B, and C recommendations. A-Level recommendations are those with the strongest evidence. Number 3 of their Level-A Recommendations is that parents and infants room share, but not bedshare (p. 1031). They based their recommendation on the results of a new meta-analysis of 11 studies comparing 2,404 cases where infants died (28.8% of whom bedshared) with 6,495 healthy controls (13.3% of whom bedshared). They calculated the odds ratio and found that it was 2.89 (95% CI, 1,99-4.18).1  Based on their calculation, bedsharing increased the risk of SIDS by almost three times. But wait…..The authors noted that there was “some heterogeneity in the analysis” (p. 45). The heterogeneity in question referred to the fact that several of the studies included infant deaths that took place on a chair or couch (a situation that greatly increases the risk of infant death), not just those that took place in an adult bed with a non-smoking, non-impaired parent.

     This issue has, of course, dogged the bedsharing debate for more than a decade. The authors themselves acknowledged that this was a difficulty (Vennemann et al., 2012).

Only recent studies have disentangled infants sleeping with adults in a parental bed from infants sleeping with an adult on a sofa. This is certainly a limitation of the individual studies and hence of the meta-analysis (p. 47).


Poster from the Milwaukee
campaign designed to warn against
the dangers of bedsharing.

But hopeful sign number 1: the AAP statement specifically differentiates between bedsharing and the broader term, “cosleeping,” which often includes all deaths that take place outside of a crib. I hope that this distinction will trickle down into future research studies.

 And there’s more. Vennemann et al. (2012) noted that bedsharing was much more hazardous with a smoking mother (OR=6.27; 95% CI, 3.94-9.99) than a non-smoking mother (OR=1.66; 95% CI, 0.91-3.01).  So there was still some increased risk if an infant slept with a non-smoking mother. But remember that this analysis included studies where babies died on couches and chairs. The next analysis was by age of infant. For infants <12 weeks, the odds ratio was 10.37 (95% CI, 4.44-24.21). But for older infants, 1.02 (95% CI, 0.49-2.12),  i.e., no increased risk.  Another analysis looked at whether bedsharing was routine. They found that if bedsharing was routine, the odds ratio was 1.42 (95% CI, 0.85-2.38). If bedsharing was not routine, but happened on the last night, the odds ratio was 2.18 (95% CI, 1.45-2.38). The authors noted that the risk was NOT significantly elevated in the routine-bedsharing group (although I note that there does seem to be some elevation in risk, probably due to the studies that included couch sharing).

     The next interesting issue is regarding their recommendations on chair or couch sharing with an infant. This has been a long-standing concern of mine due to the massively increased risk of infant death if parents fall asleep with infants on these surfaces. In fact, I have spoken with quite a few parents who routinely do this because they want to avoid bedsharing. Here’s what AAP says.

Because of the extremely high risk of SIDS and suffocation on couches and armchairs, infants should not be fed on a couch or armchair when there is a high risk that the parent might fall asleep (AAP, 2011a, p. 1033).

Further, they acknowledge—and seem to affirm—feeding babies in bed, but putting them in their own cribs for sleep.

Therefore, if the infant is brought into the bed for feeding, comforting, and bonding, the infant should be returned to the crib when the parent is ready for sleep (AAP, 2011a, p. 1033).  

     Unfortunately, this statement does not acknowledge that it’s quite easy to fall asleep in bed: 70% of mothers in our study who fed their babies in bed said that they fall asleep there (Kendall-Tackett, Cong, & Hale, 2010). And many a new parent would argue that that is precisely the point. There needs to be some recognition of, and planning for, that contingency.  But other than that, I am happy to see this recommendation included.

     The final point that I would like discuss is the role of breastfeeding in SIDS prevention, and howbedsharing has a role in sustaining breastfeeding. For example, Helen Ball (2007) found, in her longitudinal study of 97 initially breastfed infants, that breastfeeding for at least a month was significantly associated with regular bedsharing.

     We, in the breastfeeding world,have been saying this for a very long time (Academy of Breastfeeding Medicine, 2008; McKenna & McDade, 2005; McKenna & Volpe, 2007). But now theSIDS researchers are saying it too. For example, Vennemann et al. (2009) found that breastfeeding reduced the risk of SIDS by 50%. (Yes, this is the same Vennemann whose meta-analysis was cited above.) Regarding breastfeeding, Vennemann et al. (2009) said the following.

We recommend including the advice to breastfeed through 6 months of age in sudden infant death syndrome risk-reduction messages (p. e406).

     Peter Blair and colleagues (Blair, Heron, & Fleming, 2010) went further and highlighted the role of bedsharing in maintaining breastfeeding. (Peter Blair is also a co-author on Vennemann et al., 2012.)

Advice on whether bed sharing should be discouraged needs to take into account the important relationship with breastfeeding (p. 1119).

     So I am hopeful that we may be reaching a possible accord on this issue. While the AAP will probably never come straight out and recommend bedsharing, it would be helpful if they acknowledged that it will likely continue, and that our role is to help all parents sleep as safely as possible–either with or near their infants. Such a statement is possible. I’d like to close with the words from the Canadian Paediatric Society (Canadian Paediatric Society & Committee, 2004/2011).

Based on the available scientific evidence, the Canadian Paediatric Society recommends that for the first year of life, the safest place for babies to sleep is in their own crib, and in the parent’s room for the first six month. However, the Canadian Paediatric Society also acknowledges that some parents will, nonetheless, choose to share a bed with their child…..

The recommended practice of independent sleeping will likely continue to be the preferred sleeping arrangement for infants in Canada, but a significant proportion of families will still elect to sleep together…….

The risk of suffocation and entrapment in adult beds or unsafe cribs will need to be addressed for both practices to achieve any reduction in this devastating adverse event (emphasis added).

Do you talk about safe sleep in your classes? How do you address the risks and benefits of bedsharing?  Have new parents come to you after birth expressing concern about where their newborn is sleeping?  Share your experiences with talking to new parents about parenting a sleeping newborn, always a big discussion topic in the first weeks and months. – SM


[1] An odds ratio of 1.0 indicates no increased risk. Above 1.0 means increased risk. The higher the number, the worse the risk.



Academy of Breastfeeding Medicine. (2008). ABM clinical protocol #6: Guideline on co-sleeping and breastfeeding. Breastfeeding Medicine, 3(1), 38-43.

American Academy of Pediatrics, & Task Force on Sudden Infant Death Syndrome. (2011a). Policy Statement: SIDS and other sleep-related deaths: Expansion of recommendations for a safe infant sleeping environment. Pediatrics, 128(5), 1030-1039.

American Academy of Pediatrics, & Task Force on Sudden Infant Death Syndrome. (2011b). Technical Report: SIDSand other sleep-related deaths: Expansion of recommendations for a safe infant sleeping environment. Pediatrics, 128(5), e1-e27.

Ball, H. L. (2007). Bed-sharing practices of initially breastfed infants in the first 6 months of life.Infant & Child Development, 16, 387-401.

Blair, P. S., Heron, J., & Fleming, P. J. (2010). Relationship between bed sharing and breastfeeding: Longitudinal, population-based analysis. Pediatrics, 126(5), e1119-e1126.

Canadian Paediatric Society, & Committee, C. P. (2004/2011). Recommendations for safe sleeping environments for infants and children. Retrieved from http://www.cps.ca/english/statements/cp/cp04-02.htm#Recommendations

Kendall-Tackett, K. A., Cong, Z., & Hale, T. W. (2010). Mother-infant sleep locations and nighttime feeding behavior: U.S. data from the Survey of Mothers’ Sleep and Fatigue. Clinical Lactation, 1(1), 27-30.

McKenna, J. J., & McDade, T. W. (2005). Why babies should never sleep alone: A review of the co-sleeping controversy in relation to SIDS, bedsharing, and breastfeeding. Paediatric Respiratory Reviews, 6, 134-152.

McKenna, J. J., & Volpe, L. E. (2007). Sleeping with baby: An internet-based sampling of parental experiences, choices, perceptions, and interpretations in a Western Industrialized context. Infant & Child Development, 16, 359-386.

Vennemann, M. M., Bajanowski, T., Brinkmann, B., Jorch, G., Yucesan, K., Sauerland, C., . . . the GeSID Study Group. (2009). Does breastfeeding reduce the risk of sudden infant death syndrome.Pediatrics, 123, e406-e410.

Vennemann, M. M., Hense, H.-W., Bajanowski, T., Blair, P. S., Complojer, C., Moon, R. Y., & Kiechl-Kohlendorfer, U. (2012). Bedsharing and the risk of sudden infant death syndrome: Can we resolve the debate? Journal of Pediatrics, 160, 44-48.

 About Kathleen Kendall-Tackett

Kathleen Kendall-Tackett, Ph.D., IBCLC, RLC, FAPA is a health psychologist, IBCLC, and Fellow of the American Psychological Association. Dr. Kendall-Tackett is Editor-in-Chief of Clinical Lactation, President-elect of the American Psychological Association’s Division of Trauma Psychology, clinical associate professor of pediatrics at Texas Tech University Health Sciences Center, and owner of Praeclarus Press. More information on the mother-infant sleep debate can be found at http://praeclaruspress.com/sense-sensibility.html


“Don’t Sleep with Big Knives”; Interesting (and Promising) Developments in the Mother-Infant Sleep Debate

June 26, 2012 07:00 AM by Amy Peterson
I would like to see how the SIDS statistics of safe bed sharing babies compare to babies who sleep in a separate crib in their own room. Are there ANY (how many) annual recorded deaths of a breastfed baby, dying alone in bed with a non smoking, non-compromised mother?

“Don’t Sleep with Big Knives”; Interesting (and Promising) Developments in the Mother-Infant Sleep Debate

June 26, 2012 07:00 AM by Sharon Muza, BS, LCCE, FACCE, CD(DONA), BDT(DONA), CLE
Thank you, Kathy for sharing more insight and info on the Milwaukee campaign and safe cosleeping/bedsharing. The realities of parenting a newborn or young infant often do not line up with the "commercial" message parents receive from a variety of sources, including health care professionals. It is important for everyone to have resources that speak to this. I appreciate this article.

“Don’t Sleep with Big Knives”; Interesting (and Promising) Developments in the Mother-Infant Sleep Debate

June 26, 2012 07:00 AM by Rose Bertrand
How odd that when the problem is baby's sleeping with adults on a chair or couch that the picture on the brochure does not depict that with the warning circle with a slash through it. I wonder no one thought of that since it is too the point. Perhaps the point has been willfully missed.

“Don’t Sleep with Big Knives”; Interesting (and Promising) Developments in the Mother-Infant Sleep Debate

June 26, 2012 07:00 AM by mry wlsn
I am glad that cosleeping is being addressed. As an RN on the mother/baby ward cosleeping was neither encouraged nor discouraged. It was up to the parent. I have seen several incidents. One where the mother fell asleep and when I went to make rounds the baby was haning part way off the hospital bed. I woke mom up and she moved the baby closer to the middle. Another incident was where the parents did not want the baby to go to the nursery. Both parents were sleep deprived. I was the night nurse and tried several times to encourage the parents to let the baby go to the nursry so they could get a few hours sleep. The following day dad was holding the baby and fell asleep and in relaxing he let go of the baby and the baby landed on its head on the concrete floor and ended up with a fractured skull. After the fact the mom kept the baby only for feeding and the baby went back to the nursery. I have seen many mom's cosleep in the hospital with out incident. In 30 years and For as many mothers I have seen cosleep these were the only incidents that I ever came across. Taught Lamaze in 1975 to 1980 and never did adress cosleeping.

“Don’t Sleep with Big Knives”; Interesting (and Promising) Developments in the Mother-Infant Sleep Debate

June 26, 2012 07:00 AM by Jennifer J. Brodie, LCCE
I teach at a large university/teaching hospital. I teach CBE as well as a newborn care class. My co-teacher and I absolutely discuss safe sleeping, how to interpret misleading statistics about "co-sleeping" deaths, the potential benefits of co-sleeping for breastfeeding mamas and babies, and the guidelines for how to do so safely. We ask them to consider that even though many of them as *expectant* parents swear they would NEVER co-sleep with their babies, once the baby is born, the majority of parents do "admit" to co-sleeping with their babies for at least a portion of the night/early morning and many of them find it to be surprisingly wonderful and natural. We therefore want them to know how to do so as safely as possible, and under what circumstances they should not co-sleep. We let them know that it is a normal need and behavior for humans and that their baby will not necessarily die just by sleeping with his/her mother. We give them options on how to create safe sleep environments and then encourage them to make the best and safest decision for their baby and family by relying on their instincts and knowledge of their babies' needs, not ridiculous and insulting scare tactics like Milwaukee's. We've been teaching this for 4.5 years and so far, so good! :)

“Don’t Sleep with Big Knives”; Interesting (and Promising) Developments in the Mother-Infant Sleep Debate

July 11, 2012 07:00 AM by Ann F Grauer, AdvCD/AdvPCD(DONA), IBCLC, LCCE, FACCE
A big thank you to Kathy for writing this. Also, to Lamaze for publishing it. As a childbirth educator in the Milwaukee area, I can say that it feels like a war on cosleeping in our community. Period. Pushing cosleeping underground leads parents to unsafe circumstances and to unsafe circumstances that especially involve overly-tired parents. This is a recipe for disaster. The approach of the Milwaukee Health Department is that parents are not intelligent enough or invested enough to have an honest conversation about safe infant sleep---carseat, crib, stroller, sling, parent's bed, sofa, etc. As a result the death toll of "cosleeping" deaths continues to rise in Milwaukee. Separating fact from fiction is critical. I encourage parents to read James McKenna's book, "Sleeping with Your Baby: a Parent's Guide to Cosleeping". It does not promote cosleeping, rather, in a soothing, rational tone helps parents to determine what is safest and best for their own family. Two other excellent resourcses for parents and educators: 1. Jim McKenna's MotherBaby Sleep Lab at Notre Dame http://cosleeping.nd.edu/ 2. Infant Sleep Information Source (ISIS) from the UK http://www.isisonline.org.uk/about/ As educators it is vital for us to not only give parents accurate information that is not inflamatory, we must trust parents to make the right decisions for their families.

“Don’t Sleep with Big Knives”; Interesting (and Promising) Developments in the Mother-Infant Sleep Debate

August 8, 2012 07:00 AM by 2 Doulas On A Mission » Blog Archive » Cosleeping
[...] Promising Developments in the Mother-Infant Sleep Debate [...]

“Don’t Sleep with Big Knives”; Interesting (and Promising) Developments in the Mother-Infant Sleep Debate

August 13, 2014 07:00 AM by Ophelia
Thank you for this. As a bedsharing mom, I have to say how quickly I tire of this debate. With my 1st I was scared to death to sleep with him, yet had a child with undiagnosed silent reflux who regularly woke every 45-90 mins. Add to this that I was going back to work at 6 weeks & nursing & we had a very very dangerous situation going on where I was falling asleep while feeding him anywhere I was at ANY time of day, as CCK makes you extra sleepy to make it even worse. I was talking gibberish even when awake & risking my own life to commute to work (as we financially had no choice at that time for me to be home). It finally dawned on me in my sleep deprived haze that actually researching this topic would be smart, instead of just listening to the fear mongerers telling me I'd kill him if I put him in bed. Lo & behold, I put him in my bed & everything got better. I realized that I could actually make my bed a safe place for him. I could keep on nursing, get some real sleep AND drive to work without fear I'd die on the way there or going home. I could feed him day or night without having fear that he'd end up falling from my arms or smothered in the chair. It was wonderful & even better when we we finally able to diagnose is 45 min wakings & get his reflux addressed, but that took ages to happen. Initially I was blown off when asking about his waking so frequently, then when I said he was in my bed, I was blamed for his frequent walking (despite the fact he woke that frequently for 4 months BEFORE sleeping in my bed) and finally, at about 6 months, he was diagnosed. The next baby slept (wonderfully) in my bed from day one & baby #3 sleeps with me part time, as it seems to suit her. She sleeps with me when she is sleeping well there & when restless, sleeps near me in her own bed. She seems to do best with a combination method, which has also been a new adjustment for me. I am just following her lead & letting everyone get as much sleep as we can. My bed is set up for safety for the times she is there & her bed is set up near me for times she seems to be restless lying near me. I am hopeful we will see a change in public policy, education & understanding on this subject. I am also severely tired of medical professionals & medical organizations giving medical recommendations on what I consider to be non medical topics. I am fine with a Dr telling me their opinion on my child's overall growth & development, a diagnosis on a rash, injury, illness, etc. I do not need a medical opinion on everything to do with parenting. Parenting isn't a medical endeavor as far as I can see & since the Dr isn't raising my kids, there is a boundary on where I want the medical advice to end & where & how my child & family sleeps is one of those things. Everyone getting enough sleep is important to health no doubt, but beyond that, I don't want to hear it. ;)

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